2007;28;20AAP News Robert L. Rosenfield

Polycystic ovary syndrome in adolescence associated with obesity

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Volume 28 • Number 4April 2007www.aapnews.org

FOCUS ON SUBSPECIALTIES

by Robert L. Rosenfield, M.D., FAAP

Polycystic ovary syn-drome (PCOS) is nowcommonly recognized inadolescence in associationwith the increased preva-lence of obesity. Obesity isa “stress” that unmasks thedisorder.

PCOS has been rede-fined as the result of recent

research. Originally termed the Stein-Leven-thal syndrome, the association of amenor-rhea, hirsutism and obesity, now is recognizedas the tip of the iceberg of a much broaderspectrum of disorders.

A National Institutes of Health conferenceredefined the syndrome as otherwise unex-plained hyperandrogenic anovulation (men-strual irregularity and infertility) (“NIH cri-teria,” 1992), and an international reproductiveendocrinology workshop recognized a poly-cystic ovary as an alternative diagnostic crite-rion to hyperandrogenism and oligo-anovula-tion (“Rotterdam criteria,” 2004). However,a polycystic ovary in isolation is a normal vari-ant. While obesity is not a necessary feature ofPCOS, visceral obesity related to insulin resist-ance may well prove to be a central feature inthe absence of general adiposity.

Why is it important to recognize PCOS in adolescence?

PCOS is a complex trait, much like type 2diabetes mellitus, and indeed related to it.Strong heritable components of insulin resist-ance are manifest as adolescent and parentalmetabolic syndrome (a cluster of critical levelsof abdominal obesity, blood pressure, serumtriglycerides, HDL cholesterol, and glucose,especially evident as diabetes and central obe-sity) that interact with environmental com-ponents, where obesity again is a major factor.Affected girls are at increased risk for meta-bolic syndrome. PCOS menstrual irregularity

is associated with risks for infertility andendometrial carcinoma. Early diagnosis andmanagement of symptoms and delivery ofanticipatory guidance are desirable.

What symptoms should lead to screening for PCOS?

The combination of hirsutism and men-strual irregularity usually is due to PCOS, butthe diagnosis should be considered in any of thefollowing scenarios:

• moderate or severe hirsutism, treatment-resistant acne for which Accutane is beingconsidered, or pattern alopecia, in theabsence of menstrual irregularity or obesity;

• menstrual irregularity that persists morethan two years or severe dysfunctional uter-ine bleeding, in the absence of hirsutism orobesity;

• intractable obesity, in the absence of skinsigns or menstrual irregularity.

How should adolescents be screened?The diagnosis is on the firmest grounds

when hyperandrogenism is documented by ahigh plasma total or free testosterone. A spe-cialty laboratory that has established a vali-dated assay should perform testosterone deter-minations for women and children.

The blood sample should be obtained in theearly morning, on day 4 to 10 of the menstrualcycle if it is regular.

Who should be referred to an endocrinologist?

The diagnosis requires exclusion of otherendocrine disorders that can mimic PCOS.These account for about 10% to 20% of casesof hyperandrogenic anovulation and includedisorders such as nonclassic congenital adrenalhyperplasia, hyperprolactinemia, Cushing’s dis-ease, and, rarely, neoplasm. Therefore, anendocrine work-up is indicated if testosteroneexcess is documented or if symptoms progressor emerge in spite of a normal screening testos-terone level.

How should PCOS be managed in adolescents?Simple, inexpensive treatments may suffice.

For mild hirsutism, this consists of cosmeticmeasures such as bleaching, shaving and wax-ing. For menstrual irregularity, this may involvecyclic progestin therapy, such as medroxyprog-esterone every three weeks (for dysfunctionaluterine bleeding) to every other month (foramenorrhea). Diet and exercise counseling are thecornerstone of therapy for obesity.

Eflornithine hydrochloride cream or lasertherapies are local dermatologic measures thatare effective for small areas of hirsutism. How-ever, health insurance typically does not coverthem.

First-line endocrine treatment for hirsutismor menstrual irregularity that cannot be con-trolled satisfactorily by simple measures ordi-narily consists of oral contraceptive combina-tion pills (OCPs), particularly those thatcontain a non-androgenic or anti-androgenicprogestin. The addition of high-dose spirono-lactone as an anti-androgen may be helpful inmoderate or severe hirsutism that is not con-trolled by OCPs alone. Metformin, in con-junction with behavior modification, may helpameliorate the glucose and lipid complicationsof obesity and assist in appetite control. It is rea-sonable for an endocrinologist to supervisethese treatments.

Anticipatory guidance includes informingthese girls that infertility is not absolute. Theyneed to use ordinary contraceptive practices.The fertility rate ultimately is satisfactory,although reproductive endocrine treatmentsmay be needed.

These girls also need counseling about theirpropensity to obesity and its complications,particularly diabetes. In addition, immediatefamily members should be referred for screen-ing for diabetes and other aspects of metabolicsyndrome. Sisters are at about 25% risk ofdeveloping PCOS.

Dr. Rosenfield is a member of the AAP Sectionon Endocrinology.

Dr. Rosenfield

Polycystic ovary syndrome in adolescence associated with obesity

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2007;28;20AAP News Robert L. Rosenfield

Polycystic ovary syndrome in adolescence associated with obesity

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